Diabetes - Children

DEFINITION

There are two types of diabetes, Type I and Type II diabetes. TYPE I (Insulin Dependent Diabetes Mellitus) can occur at any age but most commonly develops before the age of 30 and accounts for 10 to 15% of diabetes cases. In Type I patients, the pancreas produces little or no insulin.TYPE II (Non-Insulin Dependent Diabetes Mellitus) is usually diagnosed in people over 30 years, although it can occur in children and teenagers. In Type II patients, there is impaired insulin production and insulin resistance.

DESCRIPTION

Type I diabetes is the most common type found in childhood. Treatment of Type I diabetes in children is aimed at maintaining normal growth and development, keeping blood glucose levels within a healthy range and promoting emotional well-being. Maintaining blood glucose levels within the target range involves effectively balancing food intake, exercise and insulin therapy. A treatment plan for children with Type I diabetes involves maintaining healthy eating habits and eating on schedule, checking blood glucose levels regularly, adjusting insulin according to blood glucose levels and activity levels and exercising regularly.

Type II diabetes in children and adolescents is being diagnosed at an increasing rate. In children, the risk factors for this type of diabetes include obesity, a family history of diabetes and non-Caucasian ancestry. The aim of treatment for children with Type II diabetes is normalisation of blood glucose levels and control of other associated conditions such as hypertension and elevated cholesterol. Early signs of diabetic complications, such as elevated protein in the urine, have been detected in children with Type II Diabetes. If left untreated this complication could develop into kidney damage. Treatment of Type II Diabetes may include lifestyle changes (nutrition and exercise) and possibly drug therapy.

HYPOGLYCAEMIA
To prevent hypoglycaemia (low blood sugar), meals should be eaten at the same time every day. Meals and snacks should not be skipped. As hypos also often occur during or after exercise, children with diabetes may need extra food before exercise and during any prolonged activities. Children with diabetes should be monitored just before meals (when hypos are most likely to occur) and during exercise.
Symptoms and signs of hypoglycaemia include headaches, mood changes, lack of attention or daydreaming, lack of energy or feeling of shakiness, nausea and stomach pains, sudden paleness with or without perspiration and drowsiness.
Hypoglycaemia is very serious and if not treated the child may lose consciousness and may have convulsions. At the first sign of a hypo, the child should be given sugar (e.g. 5 or 6 jellybeans, 2 heaped teaspoons of sugar in a little water or half a glass of lemonade). This should be followed with a complex carbohydrate such as a sandwich, wheat biscuit or piece of fruit. If the child does not respond within 15 minutes, another dose of sugar followed by solid food should be given. If there is still no improvement, seek medical help.

KETOACIDOSIS
Ketoacidosis is a serious problem. It occurs when hyperglycaemia (high blood sugar) is present and insulin levels are inadequate. The body begins to metabolise fats instead of glucose. Hyperglycaemia causes excessive urination with loss of electrolytes, while the breakdown of fats releases ketones into the blood. This sends the body into an acidic state which can lead to coma and death if untreated. It is most likely to occur when the child is unwell, as this increases the body's need for insulin; when insulin injections are missed; or when the dosage is too low. Ketoacidosis has a gradual onset over hours or days and symptoms include excessive urination and thirst and subsequent vomiting. It requires prompt medical attention.

COELIAC DISEASE
A recent clinical trial has found that children and adolescents with Type I diabetes also have a high risk of developing coeliac disease. This disease, a permanent intolerance to gluten, which is found in wheat and other cereals and grains, affects as many as one in 200 people in the general population. The incidence amongst people with Type I diabetes is estimated to be 10 to15 times higher than people without diabetes. Children who are diagnosed with coeliac disease and adopt an appropriate diet could reduce their long-term risks of diabetic complications, particularly eye problems, by up to 35 percent.

SCHOOL
In the school setting, allowances need to be made for children with diabetes, for the following reasons:
- They may need to drink or urinate more often than other children.
- They may need to eat outside the scheduled school eating times.
- They may need to measure their blood glucose levels or take additional doses of insulin.
- They should be checked for signs of hypoglycaemia or insulin reaction.

YOUNG CHILDREN
A young child with diabetes requires continual supervision and care. All diabetes-related tasks such as insulin injections and blood glucose readings must be performed by an adult. As the child develops, he/she will start to assume more responsibility for the diabetes tasks. There are a number of factors to consider with young children, which may make management easier.
- Toddlers can be frightened of painful procedures, so try to perform diabetes tasks quickly.
- Make testing and insulin injections fun by creating a game of it. For example, have a race to collect the glucose metre or give teddy a needle too.
- Give hugs and kisses after any diabetes-related procedure. This will help to reinforce the experience as being positive.
- A child of 4 or 5 years of age will begin to ask lots of queries. Try to make your answers as concise as possible. Small tasks may be introduced to fit in with your answers e.g. the child may push the button on the Metre and choose which finger or site to be pricked. This gives the child some control and lets the child feel that he/she is helping.
- From approximately 4 years of age it is advisable to draw the child's attention to how he/she feels during a hypoglycaemic attack (hypo). This will help the child to be more able to recognise symptoms of a 'hypo' and ask for help.

TREATMENT OPTIONS

If your child has been diagnosed with Diabetes, he/she will be referred to a Diabetes management team. The team may include a Doctor, Diabetes Educator, Dietitian, Podiatrist and Counsellor. The Diabetes team is there to ensure that your child has a normal, healthy life with a minimum of complications. The child should be educated about Diabetes at appropriate stages and should gradually assume more responsibility for the management of their Diabetes.

Lifestyle changes such as exercise and dietary modification can help to prevent the onset of Type II Diabetes in children with impaired glucose tolerance. Special efforts should be made to ensure that he/she performs at least 30 minutes of exercise daily and undertakes dietary changes to achieve moderate weight loss.

DIET HINTS

- Following a healthy eating plan and leading an active lifestyle can help improve blood glucose control and regulate bodyweight.
- Foods with a low Glycaemic Index (GI) are recommended because they lead to a small glucose response. These foods include wholegrain bread, oats, certain high fibre breakfast cereals, pasta, barley, legumes, temperate fruits, starchy vegetables such as corn and sweet potato and milk products.
- Avoid excessive sugar intake from foods such as cakes, biscuits, chocolate and confectionery.
- Limit the intake of fat, particularly saturated fat. A diet high in saturated fat interferes with diabetes control, contributes to weight gain and affects blood fat levels, increasing the risk of heart disease and other Diabetes complications.
- A Dietitian is an important member of the Diabetes management team. It is especially important for diabetic children to see their Dietitian regularly, to ensure nutritional requirements are being met at different stages of growth.

ORGANISATIONS & SUPPORT GROUPS

See the Diabetes Australia topic on the Healthpoint.

PHARMACIST'S ADVICE

Ask your Pharmacist for advice.
1) Follow the Diet Hints.
2) Ask to be shown the range of blood glucose testing monitors and insulin devices available from your Pharmacy.
3) Do not purchase any diabetes equipment until you are sure that you understand how to use it correctly.
4) Ask your Pharmacist for advice about how to best clean and care for your diabetes equipment.
5) It is advisable for a child with diabetes to carry food to treat a hypo should it occur. Jellybeans or glucose tablets from your Pharmacy are good examples.